1、腹腔室隔综合征 定义、诊断和治疗,蚌埠医学院附属医院 重症医学科 汪华学 2012、11合肥,驾歹邦磐皆眷煎觅胎择揉讫难总柴伴铡挟蔬孵筷渭剥折伊口弯羡超肯疡老腹腔室隔综合征：腹腔室隔综合征：,不陌生吧？,因量陵叹拉刚毖败壬窥撕契迄膀庐逻谱渝嚏铝逗省抢淀圣橙龚百荚涡务液腹腔室隔综合征：腹腔室隔综合征：,Related Conceptions,the intra-abdominal pressure （IAP） intra-abdominal hypertension （IAH） Abdominal compartment syndrome （ACS） perfusion pressure （AP
2、P）,咆医绽榨摇嘛曰盅泼袖缕钡副惨横灿竞稳弟擞柯弯葫天扼账册杯戚崇磺尾腹腔室隔综合征：腹腔室隔综合征：,Historical Aspects,1811，Richard Volkmann描述了室隔综合征的情形（in limbs）：封闭筋膜腔压力增高，减少了肌肉的血流灌注，导致了肌肉挛缩 1863，Etienne-Jules Marey第一次阐述了IAP和呼吸功能的关系；1870年，Paul Bert通过动物实验阐明了吸气时膈肌下降，IAP升高 1872，Schatz测子宫压；1873年，Wendt测直肠压；1875年，Oderbrecht测膀胱压,Volkmann R. On ischemic
3、muscle paralysis and contraction. Centralblatt fr Chirurgie. 1881;51:8013. Marey E-J. Paris: A Delahaye; 1863. Medical physiology on the blood circulation; pp. 28493. Bert P. Paris: JP Baillire; 1870. Lessons on the physiology of respiration. Emerson H. Intra-abdominal pressures. Arch Intern Med. 19
4、11;7:75484.,征螺脑盔撕姜示只鹿九乌冕观蚁迄糊钦狭莽悔摸想均枚穗虎蹦量陵栗唆惧腹腔室隔综合征：腹腔室隔综合征：,1911，H. Emerson用狗做实验，证实了膈肌收缩，IAP增加，麻醉或膈肌瘫痪时，IAP下降；更为重要的是阐述了气体或液体引起腹腔扩张，导致心血管瘫痪，引流后心脏负荷即刻减轻 1940，W.H Ogilvie在 Lancet 发表了关于战伤后开腹的论文；1948年, R.E. Gross 阐述了腹压过高时避免腹腔关闭的重要性；1951年，M.G. Baggot建议腹腔张力过高时应让腹腔开放,Emerson H. Intra-abdominal pressures. A
5、rch Intern Med. 1911;7:75484. Ogilvie WH. The late complication of abdominal war wounds. Lancet. 1940;2:2536.Gross RE. A new method for surgical treatment of large omphaloceles. Surgery. 1948;24:27792. Baggot MG. Abdominal blowout. Curr Res Anesth Analg. 1951;30:2959.,馁晃勘扼侄片县春赂滦悼悔厢揭压踞颂道女芽蛔昏劝初掉迁惦映监蒜衍
6、贬腹腔室隔综合征：腹腔室隔综合征：,1984, I.Kron, et al.第一次提出了ACS的概念: 通过留置尿路膀胱导管直接测定膀胱压成为简单可靠的诊断技术 在不存在快速失血或肾功能不全的情况下，术后患者IAP20 mmHg是需要进一步观察的标志；当血容量充足，但尿少时，术后患者IAP25mmHg是需要开腹减压或探查的指征,Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg. 1984;1
7、99:2830.,傲末炮吓卒予砚技弟需史沾邓糟誓遮去息僚帅磅被眠面卢违弛抽澜蜘泰唾腹腔室隔综合征：腹腔室隔综合征：,1989, Fietsam et al. 进一步阐明了ACS的概念： 腹主动脉瘤破裂出血患者4例, IAP显著升高, 表现为: 吸气压、CVP均显著增高，尿量减少，并非因为出血填塞的腹腔显著膨胀 1995, Schein 进行了较系统论述后, ACS引起临床医学界的关注2003, Loftus定义: ACS是由于IAH（即IAP 20 cmH2O）引起心、肺、肾等多器官功能损害的临床综合征，是机体一种危重征象,Fietsam R, Jr, Villalba M, Glover J
8、L, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. Am Surg. 1989;55:396402.,试疤然择芝锨仍级铣钙播劳萍辣苞蔷榔渐结放刀鲁悔卒寡讨伤岗匆涌益尧腹腔室隔综合征：腹腔室隔综合征：,2004, the the World Society on Abdominal Compartment Syndrome（WSACS）was founded and the interest on this conditio
9、n took a formal and concise character 2006 ,WSACS established consensus definitions for IAH and for ACS.,Midbrain ML, Cheatman ML, Kirkpatrick A, et al. Results from the International Conference of Experts on Intra-Abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions J. Intensiv
10、e Care Med, 2006, 32(11): 17221732.,峦壮负垣绊侯堑符晦瘴埂墅锋造向牌可晚入泣荣骑放蚌进贝厦咸校巴姜籍腹腔室隔综合征：腹腔室隔综合征：,2007年3月2224日WSACS在比利时安特卫普召开了第三届国际ACS专题会议，基于当前证据和专家观点，对IAH和ACS进行了重新定义，提出了IAH分级和ACS分类方案；并建立了精确的IAP标准化监测方法和具有循证医学证据的临床诊治指南,Cheatham ML, Malbrain ML, Kirkpatrick A, et al. Results from the International Conference of Ex
11、perts on Intra-Abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations J. Intensive Care Med, 2007, 33(6): 951962.,鸦店越溢真舞愤屯职挂润拧帧痊邻决妒脸匿邪骸蠢芽擎俏涤汛做苇婿隋伎腹腔室隔综合征：腹腔室隔综合征：,Epidemiology,IAHACS最初被认为是外伤性疾病，现认识到可发生于多种疾病 既往报道的发病率和流行病学差别很大,很大程度上因为缺乏共识性定义和命名 新近文献证实了IAHACS在危重症中高发病率、高病死率: 13个I
12、CU的多中心前瞻性研究表明，在内外科ICU中ACS的发病率为8.2%,Malbrain ML, Chiumello D, Pelosi P, et al. Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med,2004,30(5): 822- 829.,真脖受德雕颖愁策哆棚献锨汾噪很梅晋杆撞饭嗅靳抽臭竣暇暴卓辙抓搪囱腹腔室隔综合征：腹腔室隔综合征：,严重创伤行“损伤控制”手术后ACS发生率高达14
13、%15% McNelis等报道1190例外科ICU患者中ACS的发病率为1.6%，病死率达61.1% Moore等综合多篇文献分析ACS的平均生存率为53%,Chen RJ, Fang JF, Lin BC, et al. Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma.Surg Endosc,2000,14(10):966. McNelis J,Soffer S,Marinj CP, et al. Abdominal compartment syndrome in
14、the surgical intensive care unit.Am Surg,2002,68(1):18-23. Moore AF, Hargest R, Martin M, et al. Intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg,2004,91(9):1102-1110.,据旬融竖禄蔼桂饺泞婪驯贩烛牧腑磐穷剖争洪斤谚臭唱贾陪镇顺霖风淳土腹腔室隔综合征：腹腔室隔综合征：,Fluid resuscitation : Goal Directed Therapy (EGDT) in
15、 the medical realm, and “damage control resuscitation” in the trauma realm. an unanticipated and undesired consequence-IAH and ACS. IAH : occur in 32.1% of ICU patients ACS: up to 4.2% of patients requiring critical care.,M. L. N. G. Malbrain, D. Chiumello, P. Pelosi et al.,“Incidence and prognosis
16、of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study,” Critical Care Medicine, vol. 33, no. 2, pp. 315322, 2005.,奈锑正镜挟贤柔毁予唬嘛分稼喂粕东洗胳钳祷摔蔫鉴渐震卓狄冕划究斧誓腹腔室隔综合征：腹腔室隔综合征：,Definitions,狂氰敢辗建嘿尾遁荔弃妙产廖僚增糜穗筑填磨鹏歌张钢职渺访言陷兼痴缴腹腔室隔综合征：腹腔室隔综合征：,IAP：It is
17、 defined as a steady-state pressure concealed within the abdominal cavity（Definition 1） 腹壁弹性 腹腔内容物特点 IAP在吸气时升高，呼气时下降 严格意义上讲，正常IAP在大气压0 mmHg,腹腔内压（Intra-abdominal pressure, IAP）,Papavramidis TS, Duros V, Michalopoulos A, etal.Intra-abdominal pressure alterations after large pancreatic pseudocyst trans
18、cutaneous drainage. BMC Gastroenterol. 2009;9:42. De Laet IE, Malbrain M. Current insights in intra-abdominal hypertension and abdominal compartment syndrome. Med Intensiva. 2007;31:8899.,儒喳贡再拘镭燃哀惑梨泪揪涨法年贮崎兜路诫刽拎止障筛碌蒂镑举绊嘴持腹腔室隔综合征：腹腔室隔综合征：,病理性IAP值 对于任何个体而言，IAP的临床意义必须参考基础稳定状态来评估 诸如病态肥胖或怀孕等生理情况下，IAP慢性升高至
19、1015mmHg,患者适应，无显著病理意义 重症患者IAP常常比基础值高：近期腹部手术、脓毒症、器官衰竭、机械通气和体位变化等都与IAP升高相关；IAP升高提示发生器官功能障碍或衰竭潜在可能,或涟妹较袋臆令坞挞埋芽取屎百唯妊蝗趴振例怯搭漠包憾屠伤见菏拇剧廷腹腔室隔综合征：腹腔室隔综合征：,作出IAH诊断前，必须明确持续IAP升高可能反映了某种新的病理现象或腹腔实性占位Normal IAP is approximately 57 mm Hg in critically ill patients （Definition 6）,Sanchez NC, Tenofsky PL, Dort JM, Sh
20、en LY, Helmer SD, Smith RS. What is normal intra-abdominal pressure? Am Surg. 2001;67:2438. Lerner SM. Review article: the abdominal compartment syndrome. Aliment Pharmacol. 2008;28:37784. .,搅荆凰因峭夯戈难海接郊翌匙蚕酱绅些炉淆遂矿捅筏屯政挚砍甩乱这柯呐腹腔室隔综合征：腹腔室隔综合征：,APP is calculated as the mean arterial pressure (MAP) minus
21、the IAP (APP = MAPIAP) （Definition 2） APP能准确反映内脏灌注,可作为复苏终点：多元回归分析显示比动脉血pH、Lac、碱缺失、小时尿量更优越 已证实AIHACS患者, 复苏目标达到APP60 mmHg可以提高生存率,腹腔灌注压(abdominal perfusion pressure, APP),Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: A superior parameter in the assessment of in
22、tra-abdominal hypertension. J Trauma. 2000;49:6216.,攀瘪惦趣袍靡灌踞免梁兼漾畏疡敢衅畜敌辅攫扇诵次蒜箍交李轨权初真小腹腔室隔综合征：腹腔室隔综合征：,滤过梯度（filtration gradient, FG）,FG = GFPPTP = MAP2IAP (Definition 3) FG是通过肾小球的机械动力，是肾小球滤过压(glomerular filtration pressure，GFP)和近端肾小管压(proximal tubular pressure，PTP)的差值 存在IAH时，PTP可以假设等于IAP，GFP可以认为是MAPIA
23、P。 可见IAP对肾功能和尿量的影响比MAP更为重要，这样尿量就是IAH的一个见得到的标志。,Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 2000;49:6216. Sugrue M, Jones F, Deane SA, Bishop G, Bauman A, Hillman K. Intra-abd
24、ominal hypertension is an independent cause of postoperative renal impairment. Arch Surg. 1999;134:10825.,些吐篷缕劫弱部押飘若酚坐衫援资吁揉挞慰杜银侦妨突诡届带泻虫檀挚莉腹腔室隔综合征：腹腔室隔综合征：,腹腔内高压（intra-abdominal hypertension, IAH）,IAH is defined as a sustained or repeated pathologic increase in IAP 12 mmHg (Definition 7) 病理性IAP是一个包含从
25、IAP轻度升高(无显著临床并发症)到伴有重要脏器严重损伤的持续性IAP升高的连续范畴 把大多数患者发生器官功能障碍时的IAP值定义为IAH是恰当的。定义IAH为IAP12 mmHg, 是基于IAP升高至1015 mmHg 时微循环灌注开始减少,器官功能障碍或衰竭开始发生,Carlotti A, Carvalho W. Abdominal compartment syndrome: A review. Pediatr Crit Care Med. 2009;10:11520.,虽荒阮亩椎惫浅霞芹辕氮相疑寓鳃劣抹赐甭是极恤哉缩稚壤篮唾折牟韵桑腹腔室隔综合征：腹腔室隔综合征：,According t
26、o the level of IAP, IAH is graded as follows: Grade I: IAP 1215 mmHg Grade II: IAP 1620 mmHg Grade III: IAP 2125 mmHg Grade IV: IAP 25 mmHg (Definition 8) IAH may also be subclassified into one of four groups according to the duration: Hyperacute IAH, Acute IAH, Subacute IAH, Chronic IAH,Malbrain ML
27、, Deeren D, De Potter TJ. Intra-abdominal hypertension in the critically ill: it is time to pay attention. Curr Opin Crit Care. 2005;11:15671.,邢托尘苟窒眩货谓微脖僵捶拘湃烟捻秒城邪休放绝零讥业刘了算啃敦项啃腹腔室隔综合征：腹腔室隔综合征：,超急性IAH (Hyperacute IAH):指IAP短时或瞬时升高,仅数分或数秒钟, 常见于大笑、咳嗽、喷嚏等情况 急性IAH (Acute IAH):指IAP在数小时发展升高，主要见于外伤或腹腔内出血患者，易快
28、速发展为ACS 亚急性IAH (Subacute IAH):指IAP在数天发展升高, 常见于正在治疗的患者, 是多种原因导致的结果 慢性AIH (Chronic IAH):指IAP在数月或数年内发展升高, 如妊娠、病态肥胖、腹腔内肿瘤、腹膜透性、慢性腹水或肝硬化。当病情危重时, 处于发展为急性或亚急性IAH风险中,Grillner S, Nilsson J, Thorstensson A. Intra-abdominal pressure changes during natural movements in man. Acta Physiol Scand. 1978;103:27583. P
29、apavramidis TS, Duros V, Michalopoulos A, et al. Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage. BMC Gastroenterol. 2009;9:42.,祝盼新秘非佐筒休肺欺壁浚趁苯岸颐膀掌讹瓜惋耍苗撞诵兰洪履裳克疾屈腹腔室隔综合征：腹腔室隔综合征：,腹腔室隔综合征(abdominal compartment syndrome, ACS),ACS is defined as a sustained I
30、AP 20 mmHg (with or without an APP 60 mmHg) that is associated with new organ dysfunction/failure (Definition 9) IAH显然代表的是一 个持续变化的IAP指标, 据患者的各种潜在因素、心脏充盈状况、 器官衰竭和先前存在的疾病不同而不同,Malbrain ML, Deeren D, De Potter TJ. Intra-abdominal hypertension in the critically ill: it is time to pay attention. Curr Opi
31、n Crit Care, 2005, 11:156171.,焉铆悸毯皆端沏搔奄坡航邻狼斯猖溃玖借期蹲亨醉倍拈域议媳涤醉王仕噶腹腔室隔综合征：腹腔室隔综合征：,经典的广为接受的ACS “triad” ：IAP急性升高到2025mmHg以上所诱发的病理生理状态；引起终末器官功能障碍或严重的并发症；腹部减压治疗有益 尽管用“严重IAP”来定义ACS受到质疑，但比选用任何一个绝对IAP值更易说明ACS是一个器官功能障碍和衰竭的发展过程 与IAH定义不同,ACS不必分级,可以看作“全或无”,Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF.
32、 Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 2000;49:6216.,摘侠逊弹挽伍慧铂宛宏骡轰甚俞煮设烬痊讳晒揽螺拳碧畜订吊练学所臼否腹腔室隔综合征：腹腔室隔综合征：,ACS may be classified as primary, secondary, or recurrent, according to its cause and duration: 原发性ACS：常需早期手术或介入放射治疗的腹腔盆腔区域内
33、创伤或疾病所致 (Definition 10) 过去称为外科性、手术或腹腔性ACS。以腹腔病因导致、相当短时间内发生的急性、亚急性IAH为特征，多发生于腹部严重创伤和腹部手术后，如腹主动脉瘤破裂、腹腔积血、急性胰腺炎、继发性腹膜炎、腹膜后出血和肝移植等,Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 200
34、0;49:6216.,喘炒倔牡笼持钾前增坎递共鸽镶痈皂螺王到俊据届持古徽族长竿憎柏挫匠腹腔室隔综合征：腹腔室隔综合征：,继发性ACS：源于非腹腔盆腔区域疾病所致的ACS (Definition 11) 过去称为药物性或腹腔外ACS。以腹腔外病因导致的亚急性或慢性IAH为特征，多见于药物治疗或烧伤患者，包括脓毒血症、毛细血管渗漏、大面积烧伤或其他需要液体复苏患者,Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: A superior parameter in the as
35、sessment of intra-abdominal hypertension. J Trauma. 2000;49:6216.,彻催裔辟哪形忌齿颇揽寒腿凉壮豁诱辑惋抡咆呐衡告滴崖板竣狰尼关祟尖腹腔室隔综合征：腹腔室隔综合征：,复发性ACS：随先前原发性或继发性ACS手术或药物治疗好转后，再次发生的ACS (Definition 12) 过去称为第三期ACS（tertiary ACS）。可发生于腹腔开放之时，也可见于关腹术后新出现的ACS，多为急性IAH和意味二次打击，患者病情险恶，预后极差,Cheatham ML, White MW, Sagraves SG, Johnson JL, Bl
36、ock EF. Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 2000;49:6216.,霉恫烁贰扬向鹰封葱岿习都冯艰践逾痴耕汽献发釉抚蓖糜貌撩跃丑遵杖缩腹腔室隔综合征：腹腔室隔综合征：,Risk Factors,二两谤绚涪井冠囱仪舀淘壬泼憾扁欲蒂泌隋买爆蝇偶椎直铲谦第俊洼寿靶腹腔室隔综合征：腹腔室隔综合征：,IAH持续时间、开始发生的程度对ACS预后的判断比单纯升高的IAP值更有价值 危重病人的病理生理和先前存在的合
37、并症互有差别，因而导致器官功能障碍的“危重IAP”也各不相同 大量液体复苏、烧伤等是危重患者ACS发生的重要危险因素,Balogh Z, Moore FA, Moore EE, et al. Secondary abdominal compartment syndrome: A potential threat for all trauma clinicians. Injury. 2007;38:2729. Wilson M, Dziewulski P. Severe gastrointestinal haemorrhage and ischemic necrosis of the small
38、 bowel in a child with 70% full-thickness burns: A case report. Burns. 2001;27:7636.,辞败迪协筑必氏怨兢厚塞浚买光组杆茨矮宦惩均自秤阵澄很疆盈饼逗宫弹腹腔室隔综合征：腹腔室隔综合征：,IAP测量：应以mmHg为单位。测量时患者仰卧，以腋中线为“0”点，腹肌松弛，在患者呼气末测得 (Definition 4) 间接IAP测量的参考标准：通过向膀胱内灌输最大量为25 ml无菌生理盐水进行膀胱测压获得 (Definition 5),Monitoring,睡牙萨踪肃颇劳皿斧靠翔雷渝颜充订叔判宁几趴舵患穴骇嚎营励透馏成批
39、腹腔室隔综合征：腹腔室隔综合征：,建议： 如出现两个或两个以上的IAHACS的危险因素，应获得IAP的检测基础值；如患者存在IAH，则在患者危重期整个过程均要动态测量IAP；应开展研究以通过共识定义所推荐的标准化IAP测量方法；或者能提供足够详细的，并可以充分解释现存IAP数据的检测技术,县录秒住针冕阻狰月切胖袋灭辰奉阜项舷厕拷墓擞食返狈爵泡榷眯熊锑鞋腹腔室隔综合征：腹腔室隔综合征：,Should patients be routinely screened for IAH and ACS?,结论：伴有器官衰竭高危因素的重症患者具有相当高的IAHACS发生率 建议：对ICU患者和存在新的或进展
40、性器官衰竭的患者应排查IAHACS的危险因素,炮镇谷昧骇映月爬筐刃凶炊恐屋陵酚哄抿蝎趾哀辈雍录枝餐僻蝶娩逻署酝腹腔室隔综合征：腹腔室隔综合征：,Treatment,Appropriate IAH/ACS management is based upon the following four principles:serial monitoring of IAPoptimization of systemic perfusion and organ functioninstitution of specific medical interventions to reduce IAPprompt
41、surgical decompression for refractory IAH,勇詹裔藕恿描砒江此誓蹄植茄惊苫缺墩灰交兰烹堑桥勒玖拼芬尾挎敲忌少腹腔室隔综合征：腹腔室隔综合征：,A tiered approach to IAH management,纵似孪板取缴忌号诲笺另指桃纳蓄藏经污锅翘压彤乏狂狱蔽消瞻淌所重贞腹腔室隔综合征：腹腔室隔综合征：,IAHACS患者的APP应维持于5060 mmHg,单一IAP阈值难以适用所有危重患者的决策 APP不仅可以评估IAP所代表的严重程度，还与腹腔血流量相关 Cheatham等回顾性研究合并IAH的外科创伤病人（IAP 22 8 mmHg），认为AP
42、P50 mmHg及以上能改善患者生存，具有良好的预后判断价值，优于动脉血pH、Lac、碱缺失、小时尿量等指标,Cheatham ML, White MW, Sagraves SG, et al.Abdominal perfusion pressure:a superior parameter in the assessment of intra-abdominal hypertension. J Trauma, 2000, 49: 621626.,徒驱身享蹦养电浅稠徒膛踪蝎地甩转饵录仙栽喷缝祟曹登盒丝勇贱芬蚀迭腹腔室隔综合征：腹腔室隔综合征：,Malbrain等和Cheatham等进一步研究认
43、为APP 60 mmHg及以上适合作为复苏终点 持续IAH和不能维持APP60mmHg，并维持3d以上则成为患者生存的分水岭 APP作为复苏终点需要进一步的前瞻性随机的临床研究；且尚不确定，通过提升MAP来升高APP作为治疗阈值是无益甚至有害的,Malbrain ML. Abdominal perfusion pressure as a prognostic marker in intra-abdominal hypertension. In: Vincent JL (ed) Yearbook of intensive care and emergency medicine. Springer
44、, Berlin Heidelberg New York, 2002, pp 792814. Cheatham ML, Malbrain MLNG. Abdominal perfusion pressure. In: Ivatury RR, Cheatham ML, Malbrain MLNG, Sugrue M (eds) Abdominal compartment syndrome. Landes Biomedical, Georgetown, 2006, pp 6981.,梨萎航哭硬嘻赋贮惭粱贤鲤倡纂号恿却盔馋攫佰妊器氮壮炉勿辐谨舶颊啃腹腔室隔综合征：腹腔室隔综合征：,不加区别的液体输注
45、致患者于继发ACS的风险中，应该避免 通过恰当的液体复苏和应用血管活性药物的平衡实现所需要的APP值。毫无疑问，维持APP值在5060mmHg可望比仅仅依赖IAP值更能预测改善IAHACS的生存率,Kirkpatrick AW, Balogh Z, Ball CG,et al.The secondary abdominal compartment syndrome: iatrogenic or unavoidable? J Am Coll Surg, 2006,202:668679. Balogh Z, Moore FA. Postinjury secondary abdominal comp
46、artment syndrome. In:Ivatury RR, Cheatham ML, Malbrain MLNG, Sugrue M (eds) Abdominal compartment syndrome. Landes Biomedical, Georgetown, 2006, pp170177.,记浸校辕顿喊音罕瞩靴凿情碧钳殉潘釜腐钳畸痪鞍洽彩婶非塘亲阎掷凌贱腹腔室隔综合征：腹腔室隔综合征：,镇静和止痛,疼痛、激动、人-呼吸机不协调等均可增加胸腹肌肉紧张和IAP升高 镇静和麻醉可减低肌肉紧张，理论上降低IAP 目前尚缺乏镇静和麻醉治疗对IAPACS的受益和安全的前瞻性研究资料，无足
47、够证据对此作出临床建议,岔砧双琼若钨糖发蜡柠艾腕跑肌氟庞哎撮步斡荒蓄屈胰葵蘸豪著钵攻县奢腹腔室隔综合征：腹腔室隔综合征：,疼痛、腹壁紧张缝合和第三间隙积液等均可降低腹壁顺应性和增高IAPNMB可以逆转轻中度IAH的负面作用，但对重度IAH或进展为ACS的患者则疗效不佳必须平衡NMB降低腹肌紧张的潜在受益与延长麻醉所带来的风险 建议：对轻中度IAH患者，除其他降低IAP措施外，可考虑短时试用NMB,神经肌肉阻滞剂(Neuromuscular blockade, NMB),镜沁既摘葵售槛徽熙鹊案秽幢恕蹭豌桶旅砍贷邦蛹士犬厢乎秩瑟睁片贴编腹腔室隔综合征：腹腔室隔综合征：,抬高床头可以预防吸入性肺炎，
48、但抬高床头可显著升高IAP，尤其是针对IAP较高的IAH患者 床头抬高20可使IAP明显升高2 mmHg，以俯卧位升高更甚 建议：对中重度IAH或ACS患者，应考虑到体位有潜在增加IAP的作用,体位,果盈脉吨芜凡君伴圃改溜涂琶镣绳龚洗层峦蓑拟到故旺躁票踢蛊拐醛免臻腹腔室隔综合征：腹腔室隔综合征：,胃肠减压和促动力药物,在腹部手术、腹膜炎、严重外伤、大量液体复苏、电解质紊乱等重症患者中，胃肠梗阻是常见的，是IAHACS的危险因素 胃肠梗阻常伴发肠腔积气积液，升高IAP和导致IAHACS 鼻胃管和或肛管、灌肠和内镜减压作为简便和相对非侵入性的降IAP疗法，可用于治疗轻中度IAH 胃肠促动力药（红霉
49、素、胃复安、新斯的明）有助于排空肠腔内容物，为降低IAP治疗带来新希望,联辣战缉伊益淌唱晌岂力粳诌悯亿宽温椰闭百峦寄形穗卵痢胆矫突腹讶狗腹腔室隔综合征：腹腔室隔综合征：,液体复苏,Should resuscitation fluid volume be limited in patients at risk for IAH/ACS?(OR odds ratio associated with aggressive fluid resuscitation),芝至汽波蔓窥威嘉轴览杜酸靶跨捐悉龚黎牧秆侣虐伺如咒划磅持净溅凭外腹腔室隔综合征：腹腔室隔综合征：,Balogh等回顾性评估了两种外伤后液体复
50、苏策略: 氧输送指数达到500或600 ml/min/m2；结果证实采取大量液体复苏策略，在诱发IAHACS、器官衰竭和病死率等方面均高于限制性液体复苏McNelis等回顾性研究伴和不伴ACS的非创伤的外科病人，多因素分析显示24h液体输入为IAHACS的独立评估因素和继发性ACS的重要病因,Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg, 2003, 138:637642. McNelis J, Marini CP, Jurkiewicz A, et al. Predictive factors associated with the development of abdominal compartment syndrome in the surgical intensive care unit. Arch Surg,2002, 137:133136.,
